We tried to discuss the impact of early diagnosis on outcome of critical congenital heart diseases (CCHDs), current options, and their limitations in timely diagnosis, utility of pulse oximetry screening (POS), current recommendations for screening and challenges in resource constrained countries and to suggest further avenues to cover existing gaps. Evidence acquisition process was performed on the PubMed database and Google scholar for every available article in peer reviewed journals. Prevalence of congenital heart disease (CHD) at birth is estimated to be 8/1,000 live births. About 25% of CHDs are life threatening CCHDs. The current guidelines for POS recommend that all neonates in well newborn nurseries should preferably be screened after 24 h of life. A screen is taken to be positive, “out of range” or a fail if oxygen saturation is (i) <90%, (ii) <95% in right hand and one foot after three measurements (each taken 1 h apart), or iii) difference of >3% in preductal and postductal saturations after three measurements (each separated by 1 h). POS has a specificity of 99.9% for the detection of CCHDs. It has a false positive rate of 0.05% for the same. It is estimated that POS may be able to detect nearly 50%–70% of infants born with undiagnosed CCHDss. Opportunity and feasibility for POS is higher in the sick nursery even in the resource constrained setting where most of the well nurseries may not have availability of pulse oximeter, echocardiography and neonatal cardiothoracic surgery services. CCHDs can be detected early using POS which is a convenient, noninvasive and cost effective method. All necessary criteria required for inclusion to universal newborn screening panel are fulfilled by POS. The current POS guidelines are for asymptomatic newborns in well newborn nurseries. Evidence based guidelines are still lacking for screening infants in neonatal intensive care settings. We also propose here a protocol for POS in the neonatal Intensive Care Unit.

Background: Tolvaptan, a vasopressin V2 receptor antagonist, is a strong diuretic with a new mechanism of action and has good adaptation to patients with congestive heart failure. Knowledge on the proper use of furosemide, an existing therapeutic drug, is not yet sufficient. Objectives: Clinical differences when 7.5 mg of tolvaptan was added to the usual furosemide therapy were examined. Materials and Methods: Patients who required hospitalization for congestive heart failure were randomly assigned to a group treated for 7 days with furosemide alone (FRO group) and a group treated with furosemide plus tolvaptan (TLV group) for 7 days and examined for symptoms. Physical examinations were performed every day, and blood testing, including N-terminal pro-brain natriuretic peptide (NT-proBNP) level, plasma renin activity (PRA), plasma aldosterone concentration (PAC), and noradrenaline (NAD) level, was performed on days 1, 3, and 7. Results: FRO and TLV groups consisted of 51 (age, 66.4 ± 11.8 years, 62% of males) and 47 patients (67.9 ± 14.5 years, 64% of males), respectively. During the study, the TLV group had higher urine volume and decreased blood pressure due to the suppressed diuretic effect. The two groups showed significant differences in the degree of improvement of the jugular venous pressure (FRO vs. TLV groups: 6.3 ± 1.6 vs. 7.6 ± 2.5 cmH2O, P < 0.001, on day 3) and other physical findings. Although no significant differences in NT-proBNP and NAD levels were found, there were significant differences in PRA (19.8 ± 12.9 vs. 11.8 ± 8.0 ng/[mL . h], P < 0.001, on day 3) and PAC (FRO vs. TLV groups: 180.4 ± 148.4 vs. 124.7 ± 95.5 ng/mL, P < 0.01 on day 3 and 79.4 ± 73.9 vs. 56.8 ± 38.2 ng/mL, P < 0.05 on day 7). Conclusion: Adding 7.5 mg of tolvaptan to existing treatments with furosemide resulted in differences in clinical findings and neurohormonal factors, even though the degree of improvement in congestive heart failure was the same.

Background: Aspiration is a common complication among hospitalized patients, and patients undergoing cardiac surgery are at increased risk. Our aim was to determine if screening for frailty could identify patients at risk for aspiration. Patients and Methods: A prospective cohort study of patients 65 and older undergoing nonemergent heart surgery at a single community hospital for 1 year was performed. All patients were screened for frailty before surgery using the 5-m walk test. All patients were screened for aspiration before and after surgery using 90-mL water swallow challenge protocol. Preoperative risk factors and postoperative outcomes were analyzed. Results: Of 166 patients studied, 16 (9.6%) were considered frail. Eleven patients (6.6%) failed the swallow screen preoperatively, and 34 patients (20.5%) failed postoperatively. Frail patients were 3.4 times more likely to fail the postoperative swallow screen than their nonfrail counterparts (odds ratio [OR] = 3.36; 95% confidence interval [CI]: 1.42–7.96; P = 0.01). After adjusting for age, comorbidities, and surgical factors, the likelihood of aspiration risk was still three times higher in frail patients (OR = 3.01; 95% CI: 1.06–8.98; P = 0.04). Conclusions: Frail patients are at increased risk of aspiration after cardiac surgery, but frailty screening does not identify all patients at risk. The 90-mL water swallow challenge is a simple and inexpensive test that can be used to identify patients at risk for aspiration.

Objective: Studies are available from high-income countries exploring the prevalence of depression and anxiety among patients with cardiovascular diseases such as coronary artery disease, heart failure, and atrial fibrillation. Similar data are limited from low- and middle-income countries, particularly India. Data on how the quality of life (QOL) parameters are affected by common mental disorders (CMD) such as depression and anxiety are lacking. The aim of this study is to explore the prevalence of undiagnosed depression and anxiety in patients attending the arrhythmia clinic of a tertiary care hospital in Southern India and to look at their association with QOL. Methods: This cross-sectional study involved 282 patients attending the arrhythmia clinic of a tertiary care hospital in Southern India. Depression and anxiety were assessed using the “Patient Health Questionnaire-9” scale and “Hospital Anxiety and Depression Scale for Anxiety” scale, respectively. Patient demographics and potential risk factors were also assessed. Quality of life was assessed using the “Short Form Health Survey” questionnaire. Results: The proportion of patients with undiagnosed CMD (depression or anxiety or both) in our study was 45.74%. This included 32.98% with undiagnosed depression and 32.62% with undiagnosed anxiety. The presence of depression and anxiety are important determinants of quality of life. Presence of hypertension, diabetes mellitus, or smoking is not significantly associated with a poor quality of life in our study. Conclusions: Depression and anxiety are important associations of a poor quality of life. They are commonly seen among those attending the outpatient arrhythmia clinic. Having a screening program for CMD may assist in early diagnosis and intervention in those attending arrhythmia clinics.

Background: To avoid microaspiration or tracheal injury, the target endotracheal tube cuff pressure must be maintained 20–30 cmH2O. Changing in patients' positions may effect on endotracheal tube cuff pressure. The aim of this study was to investigate the effect of various patients' positions on endotracheal tube cuff pressure after adult cardiac surgery. Methods: This prospective, interventional study was conducted on 25 adult patients with orotracheal intubation for the cardiac surgery. Patients' endotracheal tube cuff pressure was assessed after surgery in a neutral starting position during an end-expiratory hold, and cuff pressure was regulated at 25 cmH2O. Then, ten changes in head position were performed: anteflexion, hyperextension, left and right lateral flexion, left and right rotation, semi-recumbent position (head elevation in 45°), recumbent position (head elevation in 10°), horizontal supine position, and finally, Trendelenburg position (10°). The observed cuff pressures were compared with the basic cuff pressure at the starting position. Results: Of total 250 measurements (25 participants in 10 positions), 109 (43/6%) were greater than the upper target limit of 30 cmH2O. In contrast, no measurements were less than the lower target limit of 20 cmH2O. 141 (56/4%) measurements were between the target limit of 20–30 cmH2O. All ten changes of patients' head position lead to statistically significant increase in endotracheal tube cuff pressure (P < 0.05). Conclusion: Simple changes in intubated patients' position could significantly increase in endotracheal tube cuff pressure that may potentially damage tracheal mucosa.

Background: After cardiac valve surgery, postoperative exercise capacity and psychosocial parameters of patients change significantly and both affect prognosis. This study aimed to analyze and clarify the relationship between changes in perioperative exercise capacity and psychosocial factors in the early phase after valvular surgery. Materials and Methods: We enrolled 48 consecutive patients who underwent valvular surgery and studied their exercise capacity, health-related quality of life (HRQOL), anxiety disorders, depression symptoms, blood samples, and echocardiograms preoperatively and 14-day postoperatively. Results: At the preoperative evaluation, the peak maximal oxygen consumption was 17.7 ± 5.9 ml/kg/min and decreased by 14.3 ± 4.4 ml/kg/min after the surgery (P < 0.0001). With regard to the HRQOL, the physical component summary (PCS) score and the role component summary scores decreased significantly after surgery (P < 0.05 for each). However, the mental component summary score increased significantly after surgery (51.9 ± 11.6 to 55.2 ± 10.4; P = 0.04). The ratios of the above the cut-off value for postoperative anxiety and depression scores were 29.1%, and 43.7%, respectively. Postoperative changes in exercise capacity were associated with variations in right ventricular function, chronotropic response during exercise, and the PCS score (P < 0.05 for each). Conclusions: Exercise capacity was reduced approximately 20% during the postoperative period in patients who underwent valvular surgery, and changes in exercise capacity were related to changes in psychosocial factors, not only cardiac functions. Therefore, it is important to evaluate not only perioperative exercise capacity but also psychosocial indicators during postoperative cardiac rehabilitation programs.

Background: The effect of aging on functional recovery after a period of crystalloid cardioplegic arrest is still a matter of debate. We hypothesized that age-dependent differences in the polyamine metabolism may contribute to such differences. Methods: Hearts from juvenile and adult Wistar rats were placed in a perfused beating heart model and given Bretschneider's cardioplegia for an ischemia period of 60 min. During reperfusion, recovery of contractile function and coronary blood flow were measured for 90 min. In addition, adult hearts received putrescine to bypass polyamine metabolism during the 1st min of reperfusion. In comparison, the effect of putrescine was analyzed from hearts reperfused after 45-min flow arrest for 90 min. The rate-limiting enzyme of the polyamine metabolism, ornithine decarboxylase (ODC), the proapoptotic enzyme bax, and the relation between SR-calcium-ATPase (SERCA2a) and a natrium-calcium-exchanger enzyme were determined on mRNA-level through real-time polymerase chain reaction. Results: Adult hearts had lower basal performance and lower SERCA mRNA expression compared to juvenile hearts. However, after a 60-min aortic clamping period, recovery of left ventricular developed pressure (105.6 ± 39.7% of baseline) in the adult group was better than in the young group (61.3 ± 34.1% of baseline). ODC mRNA was significantly (P = 0.04228) lower in adult hearts (0.60 ± 0.09-fold vs. juvenile rats). Similar, bax mRNA was significantly (P = 0.01662) lower in adult hearts (0.22 ± 0.03-fold vs. juvenile rats). Addition of putrescine to adult hearts during reperfusion attenuated a better outcome of these hearts suggesting a detrimental effect of polyamine metabolism after cardioplegic arrest. In contrast, putrescine improved recovery in postischemic hearts without exposure to cardioplegic solution. Conclusion: Adult rat hearts tolerate cardioplegia-mitigated ischemia better than juvenile hearts because they express less ODC during resubstitution of normal calcium levels.

Background: Left ventricular (LV) hypertrophy is considered to be a significant manifestation of increased blood pressure, which is associated with an increased risk of cardiovascular morbidity and mortality. Exercise training is recommended for reducing blood pressure in mild and moderate hypertensive patients. Methods: We conducted a search for interventional studies evaluating the effect of exercise on LV mass index (LVMI) in hypertensive patients. Studies were searched using different databases from 1990 to 2015. The primary end points were change in LVMI, systolic blood pressure (SBP), and diastolic blood pressure (DBP). Of 122 studies, eight studies were found to be eligible for this meta-analysis. Results: The produced effect size was found to be large for LVMI (3.6, 95% confidence interval [CI]: 1.7–5.5) and DBP (2.8, 95% CI: 1.6–3.9) with significant heterogeneity, while moderate (0.56, 95% CI: 0.35–0.77) for SBP without significant heterogeneity. The estimated predictive intervals for LVMI (95% CI: −3.2–10.3) and DBP (95% CI: −1.3–6.8) showed a positive but not significant difference in the intervention and control groups. Conclusion: The study demonstrated a significant reduction in LVMI and DBP in hypertensive patients after exercise training. A moderate reduction in the SBP of these patients was also depicted after exercise. Our study supports the American College of Cardiology/American Heart Association guidelines for regular exercise in hypertension.

For some difficult subsets of coronary patients having specific comorbidities, such as insulin-dependent diabetes and chronic renal failure, arterial myocardial revascularization could be a satisfactory option. The key question is which arteries should be used. A 58-year-old insulin-dependent diabetic patient with severe renal failure, despite previous kidney transplantation, underwent treatment of his severe and diffuse coronary disease using a composite arterial Y-graft and saphenous vein. Both internal thoracic arteries were harvested as skeletonized conduits. The patient's hospital course was totally uneventful. Fifty-six months later, the patient underwent hospital readmission due to a new (inferior) myocardial infarction. Coronary angiography showed both the progression of disease into the native vessels and occlusion of the venous graft. The Y-graft was patent and well functioning despite the presence of a preoperative left upper limb dialysis fistula. This case report emphasizes the concept that both internal thoracic arteries seem to be refractory to most aggressive forms of atherosclerosis, and that a more liberal use even for high-risk candidates could be a rational practice. However, many surgeons consider the use of both internal thoracic arteries for myocardial revascularization as a too risky strategy that has to be adopted only for young and low-risk patients.